National Comparative Audit of Overnight
Red Blood Cell Transfusion
East Midlands RTC
Prepared by
Tanya Hawkins
Clinical Audit Lead
&
John Grant-Casey
Project Manager
March 2008
National Comparative Audit of Blood Transfusion
National Blood Service
The National Comparative Audit Programme
Background information
• A series of audits designed to look at the use and
administration of blood and blood components
• Open to all NHS Trusts and Independent
hospitals in the UK
• Collaborative programme between NHS Blood
and Transplant & Royal College of Physicians
• Endorsed by the Healthcare Commission
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Why was this audit necessary?
•
The Serious Hazards of Transfusion (SHOT) report has highlighted the
increased risk of overnight transfusion and found that 37% of errors in which
the time was reported took place between 20:00 and 08:00.
•
A major learning point from the SHOT report is that transfusions should not
take place out of core hours unless clinically indicated (SHOT report 2005).
•
There is likely to be an increased risk of a transfusion complication not being
detected when a patient is transfused overnight because there may be fewer
nurses to monitor the patient and there is likely to be fewer medical and
laboratory staff available to respond to the complication.
•
Monitoring the patient at night may be more difficult than in the day time
because of reduced lighting.
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
What were the aims of this audit?
•
Establish the percentage of red cell units administered between the hours of
20:00 and 08:00 hours nationally.
•
Look in detail at 14 overnight red cell transfusions to see if they were appropriate
according to pre-defined criteria.
•
Produce a follow-up audit which hospitals can use to identify reasons why
transfusions are given inappropriately out of hours.
•
Achieve a reduction in the number of red cells transfusions which are performed
between the hours of 20:00 and 08:00 unless they are clinically or pragmatically
indicated.
•
Use the data from the report to compare the quality of patient monitoring in
patients transfused overnight during the 2008 re-audit of bedside transfusion
practice.
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Participation
We invited
• 199 NHS hospitals
• 30 Independent hospitals
Who took part
• 190 (93%) NHS hospitals sent information
• 14 (47%) Independent hospitals sent information
Number of patients audited
• Nationally = 2138 East Midlands RTC = 132
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Methodology
• Hospitals were asked to identify all units of blood collected
for transfusion in the period starting 07:31 Monday 24th
September 2007 to 07:30 Monday 1st October 2007.
• They were asked to audit 14 patients who had been
transfused in the overnight period (20:00 to 08:00).
• Hospitals selected their own cases, based on a quota
suggested by the Project Group.
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Number of cases audited
Hospital
n cases audited
A
12
B
14
C
14
D
13
E
14
F
11
G
8
H
14
J
2
K
11
L
0
M
19
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Standards used
STANDARD 1
Patients are not transfused overnight unless clinically indicated or for
practical, pragmatic reasons.
STANDARD 2
Patients transfused overnight are monitored in accordance with BCSH
guidelines.
STANDARD 3
The reason for administration of red cell transfusion is documented in the
patients’ medical records (BCSH 1999).
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
% of units collected that were transfused overnight
50
% patients transfused overnight
45
40
35
30
%
25
20
15
10
5
0
National Regional
A
B
C
D
E
F
G
H
J
K
L
M
Hospital
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
% units collected for overnight transfusion – a regional picture
40
35
30
%
25
20
15
10
5
0
National
East of
England
East
Midlands
London
North East
North West
National Comparative Audit of Blood Transfusion
South
Central
SE Coast
South West W Midlands
Yorks &
Humber
National Blood Service
Overnight red cell transfusion
Where do overnight transfusions take place?
National (4949)
Clinical Speciality
%
N
A&E
8
388
Elderly care
2
109
Gynaecology
2
120
Haematology
7
340
ITU
11
543
Maternity
4
188
Medicine
23
1131
Oncology
3
159
Orthopaedic
7
359
Paediatric
1
71
Surgery
19
961
Other
12
580
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
When do overnight transfusions take place?
National (6104)
%
N
19:31-21:30
26
156
21:31-23:30
21
1297
3:31-01:30
18
1071
01:31-03:30
12
760
03:31-05:30
10
623
05:31-07:30
13
790
Time range
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Categories for overnight transfusion used in the audit
Group 1 – Acute clinical need
• Patients with active bleeding / haemolysis at the time of transfusion
• Patients with low haemoglobin and symptoms
Group 2 – Less acute clinical need
• Patients transfused while in theatre
• Patients transfused to raise their haemoglobin prior to surgery the following day
• Patients transfused to raise their haemoglobin prior to a procedure the following
day
Group 3 – Pragmatic need
• Patients transfused so they can be discharged same/next day
• Oncology/Haematology patients with a limited line time
• Patients transfused out of hours because they are finishing off a transfusion
episode
Group 4 – Other
• Patients transfused for reasons that do not fall into the above categories
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Reason for transfusion overnight
100%
80%
60%
40%
20%
0%
National Regional
A
B
C
D
Acute
E
Less acute
National Comparative Audit of Blood Transfusion
F
Pragmatic
G
H
J
K
L
M
Other
National Blood Service
Overnight red cell transfusion
Observations within 15 minutes – Acute Clinical Need
100
90
80
70
60
%
50
40
30
20
10
0
0
0
National Regional
A
B
C
D
E
F
G
H
J
K
L
M
Hospital
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Observations within 15 minutes – Less Acute Clinical Need
100
90
80
70
60
%
50
40
30
20
10
0
0
National Regional
A
B
C
D
E
F
G
H
J
K
L
M
Hospital
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Observations within 15 minutes – Pragmatic
100
90
80
70
60
%
50
40
30
20
10
0
National Regional
A
B
C
0
0
D
E
F
G
H
J
K
L
M
Hospital
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Observations within 15 minutes – Other
100
90
80
70
60
%
50
40
30
20
10
0
0
National Regional
A
B
C
D
E
F
G
H
J
K
L
M
Hospital
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Reason for transfusion stated in the notes
100
90
80
70
60
%
50
40
30
20
10
0
National Regional
A
B
C
D
E
F
G
H
J
K
L
M
Hospital
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Best Case Scenario
There will always be clinical situations where blood transfusions are required
to be given overnight. To minimise risk to the patient they should satisfy the
following criteria:• A reason for giving the transfusion was documented in medical notes
• A good clinical reason for overnight transfusion was given, defined as
active bleeding / haemolysis or low Hb with symptoms
• The patient’s temperature, pulse or BP was monitored within 15 minutes
of the start of transfusion and the result was documented in the patient’s
notes.
• An Hb result was available within 2 days before transfusion
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
% of patients meeting Best Case Scenario criteria
100
90
80
70
60
%
50
40
30
20
10
0
0
National Regional
A
B
C
D
E
F
G
H
J
K
L
M
Hospital
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Audit Recommendations
1 - Patients without a clinical need should not be transfused overnight.
2 - Hospitals should review the practice for patients in Group 3 who are being transfused
to facilitate discharge, since it can be argued that those fit for discharge do not need
inpatient transfusions.
3 - Hospitals should review the practice for patients in Group 4, since there appears to be
neither a clinical nor a pragmatic reason for transfusing them overnight.
4 - Hospitals should include guidelines for transfusion overnight in their transfusion policy.
5 - For all overnight transfusions, (as with all transfusions), clinical staff should, within 15
minutes of the start of each unit, take and record observations in the clinical notes.
6 - Overnight transfusions should only be started if observations can be undertaken within
15 minutes of the start time.
7 - The reason for transfusion, beneficial effects and adverse incidents must be
documented in the patients’ clinical notes.
National Comparative Audit of Blood Transfusion
National Blood Service
Overnight red cell transfusion
Acknowledgements
• Project team: Tanya Hawkins, Tony Davies,
Hazel Tinegate, Liz Ambler, Derek Lowe, John
Grant-Casey and David Dalton
• Hospital staff who collected the audit data
With thanks to Mike McCarthy
National Comparative Audit of Blood Transfusion
National Blood Service
National Comparative Audit of Overnight
Red Blood Cell Transfusion
East Midlands RTC
Prepared by
Tanya Hawkins
Clinical Audit Lead
&
John Grant-Casey
Project Manager
March 2008
National Comparative Audit of Blood Transfusion
National Blood Service